PRE-PARTICIPATION PHYSICAL

Transcription

1 Academic Year Medaille College Sports Medicine 18 Agassiz Circle Buffalo, NY Dear Student-Athletes & Parents, Welcome to Medaille College Athletics. I would like to take some time to introduce our Medaille College Sports Medicine team. I am the Head Athletic Trainer, Brenda Dean, MS, ATC. My job is to develop and coordinate a Sports Medicine Program including pre-participation physical examinations, injury prevention programs, injury evaluations, injury management, injury treatment and rehabilitation, educational programs and counseling for student-athletes all in conjunction with our collaborating team physicians. We currently have additional full time and part time athletic trainers on staff to enhance coverage for your athletic teams. Our team orthopedic, Dr. Keith Stube, MD of the WNY Knee & Orthopedic Surgery PC group and his team evaluates and treats Medaille College athletes at weekly athletic training room clinics as well as seeing athletes from his offices during Medaille College Sports Medicine coordinated appointments. Dr. Stube is in charge of decisions regarding medical eligibility of all Medaille College athletes, as well as return to play decisions after injury. Cooperation between the Head Athletic Trainer, the studentathlete, and the team Physician is integral to ensuring a safe collegiate athletics experience. Please feel free to contact me via bid24@medaille.edu with questions or consult the sports medicine webpage found on the Medaille College Athletics website at any time while completing the attached pre-participation physical exam and pre-participation forms. A PRE-PARTICIPATION PHYSICAL, COPY OF INSURANCE CARD, List of ALLmedications & supplements taken and THIS PACKET are required BEFORE ANY PARTICIPATION in Medaille Athletics. Take this entire packet with you when having your pre-participation physical exam performed by your primary care physician. Your physical must be dated within 6 months of the start of your earliest season. This is an NCAA requirement. (Spring sports that have fall ball activities the fall date is what is used.) Please contact your coach or myself if you have any questions. Please send these forms to the address below BEFORE 1 week PRIOR to your 1 st team practice. This will allow not only time for them to arrive, but also time for everyone on our medical team to review your forms and follow up with you if necessary. PLEASE DO NOT attachments as photos / JPEGS. These forms will not be processed. Thank you for your cooperation. Do not leave ANYTHING blank Write legibly. Medaille College Sports Medicine Medaille College 18 Agassiz Circle Buffalo, NY Attn: Athletic Training Brenda Dean, MS, ATC. Head Athletic Trainer

2 Medaille College Athletic Training Room RULES 1. No FOOD / DRINK / CELL PHONES / HEADPHONES unless given specific permission. EXCEPTION: Headphones will be allowed on GAME DAY. 2. Keep your EQUIPMENT OUT this is not a locker room. 3. CLEAN UP AFTER YOUR SELF everything should be where it was before. 4. This is a CO-ED facility PROPER DRESS & LANGUAGE IS REQUIRED. Disrespectful language will not be tolerated towards ANYONE (present or not) this includes but is not limited to comments on: weight, age, gender, race, orientation, religion, heritage, etc. 5. Taping & Treatments will be done on a 1 st come 1 st served basis: in season sports will receive priority. 6. Athletes will NOT touch / adjust the modalities used in the Athletic Training Room. This is for your safety. 7. NO LOITERING This is not a hang out. 8. If something is locked / closed it is so for a reason DO NOT HELP YOURSELF to ANYTHING without permission. 9. ALL athletic injuries / illnesses should be reported to an Athletic Trainer the same day (24 hrs). Early intervention is often the key to early rehabilitation & return to competition. Appropriate injuries / illnesses will be referred out. Failure to comply with the above rules will result in your dismissal from the room until appropriate amends are made. Repeat offenders will be reported to the coaching staff.

3 Student-Athlete Health History Questionnaire Form Student Name (last, first): Sex: Age: of Birth: (Mo, day, yr) Sport(s): Social Security # Student Cell# Year in School (Circle one): Fr So Jr Sr _ Gr Address: Home Address: Street City State Zip Primary Parent provider of insurance / Legal Guardian Name D.O.B. Address Home Phone #: Cell Phone # Secondary Parent/ Guardian Name D.O.B. Address Home Phone #: Cell Phone #: Emergency Contact (NOT parents): Name Phone#: Relationship: Primary Care Physician (PCP) Name: PCP Phone # Insurance Provider Policy ID Number Phone # Policy Limit: Policy Deductible: Policy Co-Pay: ***Does the policy cover athletically-related injuries? Yes No Participation and Insurance Waiver - Health Insurance Information I,, hereby state: 1. I have and will maintain health insurance during my traditional sport season. 2. I understand that the College s policy is secondary to my primary health insurance and will only pay what my primary health insurance doesn t cover for accident claims. 3. I am aware that I am not covered by the College s secondary policy during the non-traditional season nor for injuries I may sustain outside of my team sponsored activities, or over-use injuries. 4. I must follow proper procedure with the Athletic Training Staff for injuries and referrals unless in an emergency situation, or the College s policy will not pay any bills. 5. I understand that bills for unreported injuries and unauthorized treatments will not be paid by the College s policy. 6. If I am injured, I will send the bills to the College (after my primary health insurance has paid) within one month after the primary health insurance has paid. 7. I understand that the College s policy will not pay late fees. 8. I understand that the College s policy will pay bills within one year of injury date. Any bills over one year of the injury date will not be paid by the school nor it s insurance. 9. I understand that the College s policy will not be responsible for medical bills and claims that my primary health insurance has rejected due to improper procedures. 10. I also understand that a CLEAR copy of both the FRONT AND BACK of my insurance card ON A SINGLE PAGE must be submitted with this form to allow for my participation in athletics. I have read the above information regarding health insurance and agree to the statements.

4 Student Athlete Authorization/Consent for Disclosure of Protected Health Information I,, hereby authorize Medaille College and its physicians, athletic trainers, athletic department personnel (i.e., coaches), and health care personnel to obtain and/or disclose protected health information and any related information regarding any injury or illness during my training for, and participation in, intercollegiate athletics to Medaille College and the National Collegiate Athletic Association (NCAA) and their employees or agents. I understand that my protected health information will be used by the College for the purpose of emergency services, insurance claims, and NCAA eligibility restrictions. I also understand that my protected health information will be used only by the NCAA s Injury Surveillance System (ISS) for the purpose of conducting research on injuries resulting from training for or participation in athletics. The ISS is a longitudinal research database that provides the NCAA, NCAA sports rules committees, athletic conferences, researchers and individual schools with summary (aggregate) injury and participation information that does not identify individual athletes or schools. The summary data provide the Association and other groups with information resource upon which base health and safety rules and policy and to examine the effectiveness of such efforts I understand that my injury/illness information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that my signing of this authorization/consent is voluntary, and that my institution will not condition any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation in NCAA or conference athletics. I also understand that while HIPAA regulations do not apply to the NCAA s use or disclosure of my injury/illness information, the NCAA is committed to protecting my privacy. I understand that the protected health information will be encoded before being transmitted from my institution to the NCAA and that neither the NCAA nor the ISS will identify me personally in a publication or disclosure of research results. Data will be stored on a secure server at the NCAA national office in Indianapolis, Indiana. This authorization/consent expires 380 days from the date of my signature below, but I have the right to evoke it in writing at any time by sending written notification to the athletic director at my institution. I understand that a revocation is not effective to the extent action has already been taken in reliance on this authorization/consent. Cardiac Statement I understand that these medical forms will be utilized to allow me to participate on intercollegiate athletic teams. Should the examination not be on file, be incomplete, or should participation be restricted on the form, I will not be allowed to participate until the circumstance is rectified. I also understand that any student-athlete with a known history of a HEART MURMUR or OTHER CARDIAC CONDITION must provide a COPY of the most recent echocardiogram with their physical forms. If history of a heart murmur is mentioned in the physical but no documentation is provided I will need to have an echocardiogram evaluation conducted before the beginning of my season. Cost associated with this will be my responsibility. I confirm that this information is accurate to the best of my knowledge. Furthermore, I understand that the following records will remain confidential and will become part of my medical records in the Department of Athletics Head Athletic Trainer s Office. I understand that even if I do not have a cardiac condition I must sign below stating that I understand this information.

5 Medaille College Athletics Informed Consent Form Student Athlete Sport(s) I hereby acknowledge that I am participating in intercollegiate activities at the Medaille College with the full realization that they may involve a significant risk of bodily injury. I understand that the injury may range in severity from minor to long term catastrophic up to and including death, or damage to property of myself and others. I am aware that it is not possible to delineate specifically each and every individual injury risk ranging from musculoskeletal to neurological. However, knowing the material risk and appreciating and reasonably anticipating that injuries and even death are a possibility, I hereby expressly assume all of the risks which could occur as a result of my participation. I agree that in exchange for and in consideration of the College permitting me to participate in this sport(s) and all activities related to it including, but not limited to travel, I hereby assume all the risks associated with the sport and agree to release and hold harmless the Medaille College, its officers, athletic trainers, agents, coaches and employees from any and all liability, actions, causes of actions, negligence, debts, claims or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the sport. Additionally, I understand that any previous injury or condition I have may predispose me to an increased risk of re-injury or increased risk of other injuries or conditions. Furthermore, I understand that in the event of any new injury, there may be short term and/or long term health related risks involved with continued participation in athletics, even after proper treatment or rehabilitation. I am aware of these risks, and fully acknowledge that any further damage to my pre-existing condition(s) is my financial responsibility. I further authorize the athletic trainers at Medaille College who are under the guidance and direction of Dr. Keith Stube & the staff of WNY Knee & Orthopedic Surgery PC, The Medaille College Athletic Department, collaborating physician, to render any first aid or preventative, rehabilitation, or emergency treatment deemed reasonably necessary to protect my health and wellbeing. ALL Pre-Existing Injuries / Conditions (Please SPECIFICALLY list all with DATES): (Should match explanations of answers to questions on history page ie. Asthma, left broken tibia, migraines etc) Family History (Health Status is good, poor, deceased) Family Member Age Health Status Age & Cause of Death Mother Father Siblings Other (blood) Relatives

6 Student Athlete Concussion Statement I understand that it is my responsibility to report ALL injuries & illnesses to my Athletic Trainer and/or team physician I have read & understand the NCAA concussion fact sheet (Athletic Training web page from Athletics website) From reading the NCAA concussion fact sheet, I am aware of the following information: A concussion is a brain injury, which I am responsible for reporting to my team physician or Athletic Trainer A concussion can affect my ability to perform everyday activities and affect reaction time, balance, sleep, and classroom performance. If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or Athletic Trainer You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or even days after the injury. I will not return to play in a game or practice if I have received a blow to the head or body that results in a concussion related symptom. Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage and even death. I understand that I need to follow our athletic head injury return to play policy prior to returning to activity. Said policy is gone over with individuals as needed. Personal History - History: Please circle (Y) yes or (N) no & comment on all YES answers on the designated space below (next page) 1. Has a doctor ever denied / restricted your participation in sports for any reason? Y N 2. Do you have ongoing medical conditions (i.e. diabetes / asthma)? Y N 3. Are you taking any prescription / non-prescription (over the counter) medicines / pills? Y N 4. Do you have asthma or allergies to medicines, pollens, foods, / stinging insects, etc? Y N 5. Do you cough, wheeze, or have difficulty breathing during or after exercise? Y N 6. Is there anyone in your family that has asthma? Y N 7. Have you ever passed out or nearly passed out DURING or AFTER exercise? Y N 8. Have you ever had discomfort, pain, or pressure in your chest DURING or AFTER exercise? Y N 9. Does your heart race / skip beats during exercise? Y N 10. Has your doctor ever told you that you have high blood pressure, high cholesterol, heart murmur, or heart infection? Y N 11. Has a doctor ever ordered a test for your heart (i.e. ECG, echocardiogram)? Y N 12. Does anyone in your family have a heart problem? Y N 13. Has any family member or relative died of heart problems or of sudden death before age 50? Y N 14. Does anyone on your family have Marfan syndrome? Y N 15. Have you ever spent the night in a hospital? Y N 16. Have you ever had surgery? Y N 17. Have you been told that you have or have you had an x-ray for neck instability? Y N 18. Do you regularly use a brace or assistive device? Y N 19. Are you missing a kidney, an eye, a testicle, or any other organ? Y N

7 Personal History - Continued History: Please circle (Y) yes or (N) no & comment on all YES answers on the designated space below 20. Have you had infectious mononucleosis (mono) within the last year? Y N 21. Do you have rashes, pressure sores, or other skin problems? Y N 22. Have you had a herpes skin infection? Y N 23. Have you ever had a head injury or concussion? Y N 24. Have you been hit in the head and been confused or lost your memory? Y N 25. Have you ever had a seizure? Y N 26. Do you have headaches with exercise? Y N 27. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? Y N 28. Have you ever been unable to move your arms or legs after being hit or falling? Y N 29. When exercising in the heat, do you have severe muscle cramps or become ill? Y N 30. Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease? Y N 31. Have you had any problems with your eyes or vision? Y N 32. Do you wear any protective gear such as goggles, face shield, or chest protector? Y N 33. Are you trying to gain or lose weight? Y N 34. Has anyone recommended you change your weight or eating habits? Y N 35. Do you limit or carefully control what you eat? Y N 36. Do you have any concerns that you would like to discuss with a doctor? Y N 37. Have you ever had an injury like a sprain, muscle, or ligament tear that caused you to miss a practice or game?y N 38. Have you have had any broken or fractured bones or dislocated joints? Y N 39. Have had a bone or joint injury that required x-ray, MRI, CT, surgery, injection, or physical therapy? Y N 40. Have you ever had suicidal thoughts or thoughts of injuring yourself? Y N 41. Have you experienced any repeated, disturbing memories, thoughts, or images of an experience from your past?y N 42. Have you ever been treated for a stress fracture? Y N If yes, how many? What body part(s) was involved? When did the injury occur? 43. Tobacco use Y N - Type: Amt. per day # years 44. Alcohol..Y N Ave. # drinks / mo. 45. Recreational Drugs EVER Y N 46. Caffeine Y N cups/glasses per day 47. Have you answered everything in this packet truthfully and honestly to the best of your knowledge? Y N Females Only 48. Have you ever had a menstrual period? Y N If yes, how old were you when you first got it 49. How many periods have you had in the last 12 months? 50. Do you ever experience cramps during your period? Yes No If yes, how do you treat them? 51. Are you on birth control pills or hormones? Yes No If yes, were they prescribed for (circle) Irregular periods / No periods / Painful periods / Birth control 52. When was your last pelvic examination? Have you ever had an abnormal Pap smear? Yes No 53. Have you ever been treated for anemia (low hemoglobin / iron)? Yes No 53. Is there any history of osteoporosis (thinning of the bones) in your family? Yes No Explanation of any YES answers from above (by number; use the back of this page if need more room):

8 PHYSICIAN USE ONLY (Must be completed w/i 6 mo. of earliest date of season- traditional / nontraditional) Age: Pulse: BP: Height: Weight: BMI: Vision: R 20/ L 20/ Glasses/Contacts Unaided Pupils: Equal Unequal Medical Appearance Eyes / Ears / Nose / Throat Hearing Lymph Nodes Heart Murmurs Pulses Lungs Abdomen Skin Genitourinary (Males Only) MUSCULOSKELETAL Neck Scoliosis Screen Shoulder / Arm Elbow / Forearm Wrist / Hand / Fingers Hip / Thigh Knee Leg / Ankle Foot / Toes Normal Abnormal Findings Initials Athlete Sickle Cell Trait Status (Freshman, Transfers & 1 st year athletes ONLY) Negative Positive ; Tested: Athlete Cleared Without Restrictions Cleared with the following recommendation: NOT cleared for All Sports Reason: Recommendation: Name of Physician (print): : Address: Phone: Signature of Physician:

9 Medaille College Athletics Declaration of Medications Print Name: Sport(s): Select 1 of the below: Athlete Initials Parent Initials I am NOT taking ANY Medication Athlete Initials Parent Initials Yes, I am taking medication(s) & if it contains a banned substance, I have obtained the required information listed below before I participate. Please CLEARLY list ALL medication that you are taking: If you are taking medication that contains ANY NCAA banned substance, it is your responsibility to obtain the documentation listed below: (For those of you with Stimulant, peptide hormones or anabolic agent medications there will be an additional form your physician needs to fill out) 1. A letter from your Doctor stating the need for the use of the medication. 2. What the diagnosis is and how it was reached- include test results. 3. What the course of treatment is. 4. The student-athletes medical history 5. A copy of the prescription showing dosage and frequency of use. Consult for more information on NCAA banned substances (Parents signature required if Student-Athlete is UNDER Age 18) By checking above and signing below, I acknowledge that I have read, accepted and understand, and will comply with all of the above policies and procedures. I also acknowledge that if initially I did not understand, I have contacted the Medaille College Athletic Dept. to clarify any issues I did not understand and have had those issues clarified. This signed form is required prior to participation in any intercollegiate athletics at Medaille College. Parent signature required if student-athlete is under the age of 18. Athlete Name Signature Parent Name Signature (if under 18 years old)

10 FRESHMEN, TRANSFERS & 1 st year athletes ONLY Sickle Cell Trait Status: Education, Awareness and Testing Waiver Definition of Sickle Cell Trait: Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. During intense exercise, red blood cells containing the sickle hemoglobin can change from round to quartermoon, or sickle. Sickled red blood cells may accumulate in the bloodstream during intense exercise, blocking normal blood flow to tissues and muscle. During intense exercise, athletes with sickle cell trait have experienced significant physical dis-tress, collapsed and even died. Heat, dehydration, altitude and asthma can increase the risk for complications associated with sickle cell trait, even when exercise is not intense. People at High Risk for Sickle cell Trait: People at high risk for having sickle cell trait are those whose ancestors come from Africa, South or Central America, India, Saudi Arabia and Caribbean and Mediterranean countries. Eight percent of the U.S. African American population has the sickle cell trait but ANY person may carry the trait. Information regarding your sickle cell trait status can be retrieved from your primary care physician, pediatrician, or hospital of birth. How can I prevent a collapse: Engage in a slow and gradual preseason conditioning program. Build up your intensity slowly while training. Use adequate rest and recovery between repetitions. Avoid pushing with all-out exertion longer than two to three minutes without a rest interval or a breather. Stay well hydrated at all times, especially in hot and humid conditions. Maintain proper asthma management. Be aware when adjusting to a change in altitude. Avoid using high caffeine energy drinks or supplements. If you experience symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness, stop activity immediately and notify your athletic trainer and/or coach. Sickle Cell Trait Testing: The NCAA recommends that all Division III student athletes have knowledge of their sickle cell trait status and provide proof of testing/results. If not previously tested, the athlete should consider being tested at their own cost and provide proof of testing/results, or sign a testing waiver before participation in any intercollegiate athletics event, including strength and conditioning sessions, try outs, practices, competitions etc. Athletes may inquire about their sickle cell trait status with their pediatrician or the department of records at their hospital of birth. PLEASE CHECK THE OPTION THAT APPLIES TO YOU 1) I KNOW my sickle cell trait status is NEGATIVE and proof of testing/ results is attached 2) I KNOW my sickle cell trait status is POSITIVE and know the risks associated with it and would like to participate. Proof of testing/ results is attached. I have been counseled and have watched NCAA video. 3) I DO NOT KNOW my sickle cell trait status and would like to be tested at my own expense. 4) I DO NOT KNOW my sickle cell trait status and WAIVE the right to be tested. I understand the risks associated with the trait, have been counseled and watched NCAA video. (If you choose to be tested, results must be made available prior to participation. Student athletes should be tested during the summer prior to arriving at Medaille and include documentation with the pre-participation physical) Testing may be arranged via QUEST DIAGNOSTICS at the following website: or through your primary care physician. It is my express intent that this waiver shall bind my family, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue Medaille College, its trustees, officers, agents, and employees. I hereby further agree that this sickle cell trait testing waiver shall be construed in accordance with the laws of the State of New York. In signing this release, I acknowledge and represent that I have read the foregoing, Sickle Cell Trait Testing Waiver Release understand it and sign it voluntarily; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by the same. Signature of Student-Athlete Signature of Parent/Guardian (if under 18)